Longitudinal Trends in Severe Traumatic Brain Injury Inpatient Rehabilitation.

OBJECTIVE: The goal of this study is to describe national trends in inpatient rehabilitation facility (IRF) discharges for the most severely disabled cohort of patients with traumatic brain injury (TBI). METHODS: Data from the Uniform Data System for Medical Rehabilitation for patients discharged from an IRF between January 1, 2002, and December 31, 2017, with a diagnosis of TBI and an admission Functional Independence Measure of 18, the lowest possible score, were obtained and analyzed. RESULTS: Of the 252 112 patients with TBI discharged during the study period, 10 098 met the study criteria. From 2002 to 2017, the number of patients with an IRF admission Functional Independence Measure of 18 following TBI discharged from IRFs annually decreased from 649 to 488, modeled by a negative regression (coefficient = -2.97; P = .001), and the mean age (SD) increased from 43.0 (21.0) to 53.7 (21.3) years (coefficient = 0.70; P < .001). During the study period, the number of patients with the most severe disability on admission to IRF who were discharged annually as a proportion of total patients with TBI decreased from 5.5% to 2.5% (odds ratio = 0.95; P < .001) and their mean length of stay decreased from 41.5 (36.2) to 29.3 (24.9) days (coefficient = -0.83; P < .001]. CONCLUSION: The number and proportion of patients with the most severe disability on IRF admission following TBI who are discharged from IRFs is decreasing over time. This may represent a combination of primary prevention, early mortality due to withdrawal of life-sustaining treatment, alternative discharge dispositions, or changes in admitting and reimbursement practices. Furthermore, there has been a decrease in the duration of IRF level care for these individuals, which could ultimately lead to poorer functional outcomes, particularly given the importance of specialized rehabilitative care in this population.

For-Profit and Not-for-Profit Inpatient Rehabilitation in Traumatic Brain Injury: Analysis of Demographics and Outcomes.

OBJECTIVE: To describe differences in characteristics and outcomes of patients with traumatic brain injury by inpatient rehabilitation facility (IRF) profit status. DESIGN: Retrospective database review using the Uniform Data System for Medical Rehabilitation. SETTING: IRFs. PARTICIPANTS: Individual discharges (N=53,630) from 877 distinct rehabilitation facilities for calendar years 2016 through 2018. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Patient demographic data (age, race, primary payer source), admission and discharge FIM, FIM gain, length of stay efficiency, acute hospital readmission from for-profit and not-for-profit IRFs within 30 days, and community discharges by facility profit status. RESULTS: Patients at for-profit facilities were significantly older (69.69 vs 64.12 years), with lower admission FIM scores (52 vs 57), shorter lengths of stay (13 vs 15 days), and higher discharge FIM scores (88 vs 86); for-profit facilities had higher rates of community discharges (76.8% vs 74.6%) but also had higher rates of readmission (10.3% vs 9.9%). CONCLUSIONS: The finding that for-profit facilities admit older patients who are reportedly less functional on admission and more functional on discharge, with higher rates of community discharge but higher readmission rates than not-for-profit facilities is an unexpected and potentially anomalous finding. In general, older, less functional patients who stay for shorter periods of time would not necessarily be expected to make greater functional gains. These differences should be further studied to determine if differences in patient selection, coding and/or billing, or other unreported factors underlie these differences.

Rehabilitation of Sport-Related Concussion.

This article provides a summary of clinical assessment methods and nonpharmacologic rehabilitation techniques used for concussed patients. It describes concussion-relevant physical examination methods to identify underlying symptom generators. This approach allows practitioners to prescribe targeted rehabilitation therapies to treat postconcussion symptoms. Evidence-based rehabilitation approaches include cervical rehabilitation, vestibulo-ocular rehabilitation, and sub-symptom threshold aerobic exercise.

Using a Workshop Format for Physiatry Trainees in the Management of Acute Sports-Related Concussion.

Select residency and medical student training programs have developed and researched skill-based workshops, focusing on mastering a surgical or communication skill; however, they are less frequently studied in physiatry residency programs. Given the importance of concussion care in physiatric practice, this study sought to measure the effectiveness of a novel sports-related concussion workshop. Based on the 5th International Consensus Statement on Concussion in Sport, a 6-hr concussion workshop was developed. Participants were administered a preworkshop and postworkshop questionnaire to gauge level of comfort managing various aspects of concussion, case-based questions to assess participant knowledge, and questions regarding satisfaction with workshop-based training sessions. Sixteen participants, ranging from PGY-2 to PGY-5, were included in the analyses, with significant gains (P < 0.0001 to P = 0.0045) made in all measures of comfort managing sports-related concussion; the study was unable to detect a statistically significant improvement in knowledge as assessed by the patient vignettes (P = 0.17), but participants did report high levels of satisfaction with workshop-based training sessions. Thus, workshop-based physiatry trainee education sessions can be used to teach trainees certain skills or provide comprehensive training in the management of a specific condition. Participants demonstrated improved comfort managing concussion, a trend toward improved knowledge, and a high degree of satisfaction with the content's method delivery.

Changes in Patient Demographics and Outcomes in the Inpatient Rehabilitation Facility Traumatic Brain Injury Population from 2002 to 2016: Implications for Patient Care and Clinical Trials.

Initial studies examining patient demographics and outcomes in traumatic brain injury (TBI) suggest a trend toward increasing patient age and decreasing rehabilitation length of stay, but such studies have not been repeated since the passage of healthcare reform legislation, most notably the Affordable Care Act. This study utilized the Uniform Data System for Medical Rehabilitation® (UDSMR) for patients admitted to medical rehabilitation facilities after sustaining a TBI from January 1, 2002 through December 31, 2016. Trends for demographic and medical data were evaluated. In total, 233,843 patients from 1290 facilities were included; mean patient age increased from 54.1 to 64.8 years, rehabilitation length of stay decreased from 19 to 14.5 days, and mean admission Functional Independence Measure® (FIM) decreased from 56.9 to 54.5. Sex and racial distribution remained relatively stable across all years, as did discharge FIM. There was an increase in Medicare patients from 40.7% to 62.1%, a concomitant decrease in commercially insured patients from 29.2% to 15.4%, and a decrease in unreimbursed patients from 7.2% to 2.6% over the course of the study. Based on these data, medical rehabilitation facilities appear to be admitting an older TBI patient population that is less functional on admission and discharging them after shorter rehabilitation lengths of stay. Similar discharge functional status, despite shorter rehabilitation lengths of stay and an older population may suggest a change in the typical mechanism of injury. Many current TBI patients would fail to meet inclusion criteria for post-acute clinical trials in TBI because of their age, and treatments based on such trials may not be generalizable, which has significant implications on both research and clinical care realms within brain injury rehabilitation.